Provider Demographics
NPI:1083247340
Name:NICKERSON, NATHANIEL ADAM
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:ADAM
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 E 2ND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1428
Mailing Address - Country:US
Mailing Address - Phone:509-455-6002
Mailing Address - Fax:
Practice Address - Street 1:11919 W SUNSET HWY STE A
Practice Address - Street 2:
Practice Address - City:AIRWAY HEIGHTS
Practice Address - State:WA
Practice Address - Zip Code:99001-9466
Practice Address - Country:US
Practice Address - Phone:509-356-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-14
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WAPT614222222222220166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician